journey from skin to disc in a transforaminal surgery .pptx

journey from skin to disc

1. How to perform a simple disc: skin to disc journey. Dr.Narendra Arun Bhagwat consultant endoscopic spine and neurosurgeon akola

2. Transforaminal Endoscopy Precise ART ; philosophy has evolved from debulking to precisely “TARGETED FRAGMENTECTOMY ” W here you land determines the exact ability to remove fragment and treat pathoanatomy Basic Targeting: has been de t ermi n ed by boundaries of Kambins Triangle

3. Kambin’s Triangle Holy grail : That cannot deviate as safety is paramount and every single time targeting has to land you in the Kambin’s triangle between the two end plated and nerves

4. Steps Skin marking: mark the midline identify and mark the disc marking of depth of disc I nsertion of needle I nsertion of guide wire Dilator over guide wire P lacement of canula

5. STEP 1 : inserting the Needle Needle insertion is “ KEY to ALL SURGERY ”. It has to be exact and precise . Proper use of needle is the CORNESTONE of any successful Endoscopic Spine Surgery

6. Principles of needle insertion Two sizes: 18Gx20 cms and 18G x 25 cms (obese and Tall individuals). Graduated markings of 1 cm along its length Triple marking at every 5 cms with a stopper for safety It is with a leur lock , which faces the bevel end

7. Principles of needle insertion Needle will deviate away from the surface of the bevel edge. Good endoscopic spine surgeon can make a needle dance to his tunes: he can guide it deeper , shallower , cranial or caudal.

8. AP view : Direction Lateral view :Depth

9. 1)First give way is thoracolumbar fascia . 2) needle feels light and next resistance is intertransverse ligament.** 3) annulus.

10. Aim: to reach the posterolateral corner of disc corelating with the medial pedicular line. rough Markers for average Indian 9 cm : outside the foramen near lateral pedicle line and hitting the facet 9.5 cms : mid pedicular line, just in facetal window within the foramen 10 cms : medial pedicular line edge of thecal sac : in lateral must be touching posterior annulus 12 cm : AP middle interspinous line with lateral post ¼ quadrant in disc.

11. The guide wire 0.9 mmx41cms long malleable steel wire which passes through the endoscopy spine surgery needle. Guide wire is the pillar on which all subsequent instruments pass. After passing the guide wire, gradually remove the needle with twisting movements, keeping thumb on guide wire. Ensure guide wire with gentle pressure avoiding accidental breech of disc Always make sure the tip of guide wire is straight.

12. The dilator Dilator is used to dilate a path in the most atraumatic manner to the foramen and spinal disc. It is 22 cms long Has two working channels in it: central and eccentric. Proximal bit of 15 mm taper one is of higher density to help visualize its exact position in foramen.

13. Use of dilator to gain more horizontal entry using facet as fulcrum Patients with large facets not allowing horizontal entry: one can remove the guide wire on passing of facet and hinge the dilator on the facet to gain more horizontal entry

14. The Sleeve (cannula) Sleeve is 17 cms in length Centimeter graduated markings Sleeve is mounted on a dilator ALWAYS Tip is called tang Opening is bevel cut Bevel tip is biggest contribution by Dr.Yeung Allowing visualization of both intradiscal and epidural space simultaneously Proximal end of sleeve has water inlet or hilt which is always in direction of bevel cut surface opp to tang, helping surgeon to know where he is l;ooking

15. thumb exiting root & index finger traversing root , v represents axilla and MCP of thumb drg of exiting route : manipulting tang away from axilla

16. Thank you